Hypotension and bradycardia,a serious adverse effect of piribedil,a case report and literature review

Background

Dopamine agonists (DAs) are efficacious for the treatment of motor and nonmotor symptoms in patients with Parkinson’s disease (PD). The treatment of PD with DAs is often complicated by adverse drug reactions (ADRs) of dopaminergic and non-dopaminergic origins. The DA piribedil is widely used in Asian, European, and Latin American countries; therefore, its ADRs are pertinent to clinicians. Here we present a rare case of hypotension and bradycardia that is significantly related to the dosage of piribedil.

Case presentation

A middle-aged male, diagnosed with PD, received dopamine replacement with piribedil. When taking 50?mg piribedil daily dose, the patient didn’t feel any discomfort. Two hours after taking 100?mg piribedil he presented with serious concomitant hypotension and bradycardia with a blood pressure (BP) reading of 85/48?mmHg and a heart rate (HR) of 45 beats/min when sitting. After taking 75?mg piribedil, the patient showed the same symptoms with BP reading at 70/45?mmHg and HR of 47 beats/min in the same position. Upon replacing treatment with pramipexole 0.125?mg, 0.25?mg, and 0.375?mg three times a day, no further cardiovascular effects persisted.

Conclusions

No studies have previously reported the simultaneous observation of position-unrelated hypotension and bradycardia after taking small doses of piribedil. More studies are needed to explore the effects of DAs on BP and HR, especially piribedil. Piribedil is efficacious for the treatment of PD, but it is important to weigh the potential risk of hypotension and bradycardia against the clinical benefits of this drug.

     

Plasma levels of C19 steroid glucuronides in pre-menopausal women with non-classical congenital adrenal hyperplasia.

Recent reports have thrown doubt on the role of measurements of plasma 5 alpha-androstane-3 alpha,17 beta-diol glucuronide (3 alpha-diolG) as a marker of peripheral androgen metabolism in women with polycystic ovarian syndrome and idiopathic hirsutism. It has been suggested that a plasma profile of C19 steroid glucuronides may be more informative. While preliminary data indicates that both 3 alpha-diolG and androsterone G (ADTG) may arise from adrenal steroid precursors, there have been no reports of C19 steroid glucuronides in women with non-classical, or late-onset congenital adrenal hyperplasia (NC-CAH), who constitute a significant proportion of the hirsute female population. We therefore measured plasma levels of 3 alpha-diolG, ADTG and dihydrotestosterone G (DHTG) before and following a standard Cortrosyn test in 15 symptomatic and 3 asymptomatic NC-CAH patients, 5 heterozygote carriers for 21-hydroxylase deficiency (NCHETS) and 18 normal women. The effects of chronic glucocorticoid (GCR) therapy (greater than 3 months) on the C19 steroid glucuronide profile in the symptomatic patients was also investigated. Baseline plasma levels of all 3 glucuronides were significantly (P less than 0.001) higher in symptomatic patients compared with either normals or NCHETS. However, the order of discrimination was ADTG greater than 3 alpha-diolG greater than DHTG. There were no significant differences between steroid glucuronide levels for NCHET and normal women and the C19 steroid glucuronide concentrations for the asymptomatic NC-CAH patients were greater than 2 SD above the normal means. Moderate clinical improvement was observed in all patients receiving oral GCR therapy and was accompanied by approx. 80% suppression of the plasma levels of all 3 C19 steroid glucuronides. This contrasts with a mean suppression of androstenedione of only 50%. However, plasma levels of the C19 steroid glucuronides were not significantly increased in response to a short ACTH stimulation test. This may be explained by the fact that the androgen glucuronides are thought to be peripherally formed metabolites derived from unconjugated glandular secreted androgen precursors and thus their synthesis at 60 min following adrenal stimulation may lag substantially behind that of their respective precursors. There were significant linear correlations between the levels of all 3 glucuronides, but neither correlated with Ferriman-Gallway scores, body mass index or 17-hydroxyprogesterone levels.(ABSTRACT TRUNCATED AT 400 WORDS)     

Psychological effects of subthreshold exposure to the putative human pheromone 4,16-androstadien-3-one

Research on human putative pheromones has recently focused on the effects of exposure to 4,16-androstadien-3-one (androstadienone). This steroid has been observed in the skin, axillary hair, and blood plasma, primarily in males. In addition to effects of the steroid on measures of physiological arousal and brain blood flow, positive mood effects have also been reported. The current study further investigated mood effects of androstadienone exposure (250 microM) in women in two experiments. Through psychophysical testing of each individual we controlled for whether any observed mood effects could be related to sensory detection of the steroid. In both experiments, we observed positive changes of women's feeling of being focused, which could not be related to sensory detection of the steroid. Overall, the patterns of results were significantly correlated between the two experiments. In conclusion, this study corroborates earlier findings suggesting that androstadienone exposure yields effects on women's mood; the feeling of being focused. The mood effects were not dependent on menstrual cycle phase. Further, these effects are replicable and occur also when androstadienone detection is rigorously controlled for across variation in menstrual cycle.     

Prophylaxis of recurrent venous thrombosis with long-term enhancement of fibrinolysis.

The effects of 6 months' combined therapy with phenformin and an anabolic steroid were compared in patients with thrombophlebitis migrans (12 patients) and those with superficial thrombophlebitis (15 patients). In both groups of patients an increase in blood fibrinolytic activity, and "capacity" decrease in platelet adhesiveness, plasma fibrinogen, blood lipids, beta lipoproteins as well as serum cholesterol level were found. A statistically significant decrease in frequency of inflammations in patients with thrombophlebitis migrans occurred. In these patients a return of the previously low "fibrinolytic capacity" to normal values was observed. It seems that prolonged activation of fibrinolysis by means of phenformin and an anabolic steriod may be of value in the prophylaxis of venous thrombosis especially thrombophlebitis migrans.     

Urinary cortisol and cortisol metabolites in women with idiopathic hirsutism.

Urinary unconjugated cortisol, total 17-oxogenic steroids and cortisol metabolites (THF, allo-THF, THE, cortol and cortolone) were measured in 90 normal women and in 90 women with idiopathic hirsutism of comparable age group. After carrying out Student's "t"-test, the mean steroid excretion values in hirsute women were significantly higher than those from normal females. The results indicate that, due to stress, these hirsute women do have altered adrenocortical function, as assessed by the estimation of these corticosteroids of which urinary unconjugated cortisol was found to be the most sensitive index.     

A comparative study of the locomotor activity effects of apomorphine and the "atypical dopamine agonists" (piribedil and S3608)

Apomorphine and the "atypical dopamine agonists" (piribedil and S3608) dose dependently increase locomotor activity (LA) in rats. The LA effects of all 3 drugs are readily attenuated by pretreatment with pimozide or sulpiride. Reserpine pretreatment or bilateral 6-hydroxydopamine lesions of the nucleus accumbens (NAS) potentiates apomorphine-induced LA but attenuates piribedil- and S3608-induced LA. The latter suggests an indirect mode of action for piribedil and for S3608. However, piribedil and S3608 at concentrations up to 10(-4)M do not cause release or inhibition of 3H-dopamine uptake in synaptosomes prepared from the rat NAS. Sulpiride antagonism of apomorphine-induced LA is surmountable by increasing the dose of apomorphine. Antagonism of piribedil- or S3608-induced LA by sulpiride is not surmountable by increasing the dose of either of the "atypical dopamine agonists". Furthermore, pretreatment with either piribedil or S3608 substantially increases the peak LA inducible by apomorphine. The effects of simultaneous injections of piribedil and S3608 are, however, not additive. These findings suggest that the LA stimulant effects of piribedil and S3608 are mediated via receptors or systems which differ from the receptors involved in the mediation of apomorphine-induced LA.     

Lysosomal enzymes in pregnant and steroid treated rats

The contents of three lysosomal enzymes (beta-hexosaminidase, beta-glucuronidase and alpha-fucosidase) were studied in plasma and different tissues of pregnant and steroid treated rats. All these enzymes were found to be increased in plasma from pregnant rats in analogy with the findings in pregnant women. In liver tissue only beta-hexosaminidase and alpha-fucosidase were significantly increased. In rats with diethylstilbestrol (DES) and a combination of DES and progesterone, there was an increase of alpha-fucosidase in plasma and liver. No significant changes were observed for the other two enzymes. Thus, steroid treatment did not fully reproduce the enzyme changes seen in pregnancy, which may indicate that these are not solely due to a hormone effect.     

Determination of piribedil and its basic metabolites in plasma by high-performance liquid chromatography

A high-performance liquid chromatographic method for the determination of piribedil and its p-hydroxylated, catechol and N-oxide metabolites in plasma is described. After addition of an internal standard (buspirone), the plasma samples were subjected to a three-step extraction procedure. The final extracts were evaporated to dryness under nitrogen, and the residues were reconstituted in 100 μl of mobile phase (0.01 M phosphate buffer—acetonitrile, 50:50, v/v) and chromatographed by acetonitrile gradient elution on a C₁₈ reversed-phase column coupled to an ultraviolet detector set at 240 nm. The method was selective for piribedil and its metabolites, and sufficiently sensitive and precise for studies aimed at elucidating the role of the metabolites in the parent drug's pharmacological effects.     

Deuterium labelled steroid hormones: tracers for the measurement of androgen plasma clearance rates in women

A method employing stable isotope-labelled tracers and gas chromatograph-mass spectrometry (GC-MS) analysis has been used to measure the plasma clearance rates (PCR's) of androstenedione (A) and testosterone (T) in normal women and women with androgen abnormalities including hirsutism and polycystic ovary syndrome. A solution of deuterium-labelled A and T is infused at a constant rate and blood samples taken at 2 and 2.25 h. Solvent extracts of the derived plasma samples, to which an internal standard has been added, are derivatized with pentafluoropropionic anhydride and the endogenous steroid and deuterated steroid are quantitated after an injection of the derivatization mixture into a capillary column GC-MS. The concentration of the deuterated steroid in the infusion mixture is measured and the PCR is calculated. In premenopausal normal women the PCRA is 1950 +/- 184 1/24 h (n = 5) and the PCRT is 484 +/- 82 1/24 h (n = 7).     

Heterosexual men and women both show a hypothalamic response to the chemo-signal androstadienone

The odorous steroid compound 4,16-androstadien-3-one (androstadienone), found in axillary sweat, was previously reported to evoke hypothalamic activation in heterosexual women, but not in heterosexual men. However, subjects were exposed to the pure crystalline form of androstadienone, which raised the question whether the observed hypothalamic response is physiologically relevant. Therefore, in the present study, we asked whether sexually dimorphic hypothalamic responses could be measured when subjects were exposed to lower, more physiologically relevant concentrations of androstadienone. A total of 21 women and 16 men, all heterosexual, participated in our functional magnetic resonance imaging study (fMRI). Three different concentrations of androstadienone diluted in propylene glycol (10 mM "high," 0.1 mM "medium" and 0.001 mM "low") were delivered to the subjects' nostrils using a computer-controlled stimulator. When exposed to the "high" androstadienone concentration, women showed stronger hypothalamic activation than men. By contrast, men showed more hypothalamic activation when exposed to the "medium" androstadienone concentrations in comparison to women. Thus, we replicated that smelling the chemo-signal androstadienone elicits a hypothalamic activation. However, this effect does not seem to be gender-specific, because androstadienone activated the hypothalamus in both men and women, suggesting that androstadienone exerts specific effects in heterosexual individuals of both sexes.     

Response of plasma aldosterone to orthostatism during follicular and luteal phases of the normal menstrual cycle

The responses of plasma aldosterone (A) and plasma renin activity (PRA) to orthostatism have been evaluated in 47 women during the follicular and/or luteal phase of the menstrual cycle. Three postmenopausal women and 51 men were also studied for control. Fourteen cycling women and 11 men were studied on a low sodium diet (20 mEq/day) while the rest of the subjects were on normal sodium intake. In addition, 18 women (including those postmenopausal) and 17 men were studied after intravenous administration of 20 mg frusemide. The response of A to orthostatism in women during luteal phase on normal sodium diet with or without frusemide was much greater than in men or women during follicular phase (p less than 0.01) or menopuase (p less than 0.05). However, no differences between groups could be observed in A response while on a low sodium diet. PRA response was similar during follicular of luteal phase fo the cycle as well as in men either on low or normal sodium intake with or without frusemide.     

Stimulation of tyrosine phosphorylation by progesterone and its 11-OH derivatives: dissection of a Ca(2+)-dependent and a Ca(2+)-independent mechanism

Progesterone has previously been shown to exert non-genomic effects on human spermatozoa by opening plasma membrane ion channels and by stimulating protein tyrosine phosphorylation. Here we examined how these two activities are influenced by 11-hydroxyl substitution of the steroid molecule either in the alpha- or in the beta-configuration. Both the 11alpha-OH and the 11beta-OH derivatives of progesterone were more effective than progesterone in stimulating tyrosine phosphorylation, although 11alpha-OH-progesterone was a markedly weaker Ca(2+)-influx inducing agonist than the other two steroids. In Ca(2+)-containing medium, the agonist activity of the 11alpha-OH derivative was weaker than that of the 11beta-OH derivative, and it was completely abolished by genistein, whereas that of progesterone and its 11beta-OH derivative was inhibited only partly by this drug. In contrast, when applied in Ca(2+)-free medium, the 11alpha-OH derivative was the strongest of the three agonists tested, and the effects of all the three steroids were completely abolished by genistein. These data show that the structural motifs of steroid molecules that are responsible for the stimulation of tyrosine phosphorylation are different from those mediating the steroid action on Ca2+ influx through plasma membrane channels. The synthesis of selective agonists of both activities may lead to the development of new pharmacological agents to be used in the treatment of steroid-dependent pathologies.     

Urinary pregnanetriol and delta 5-pregnentriol in women with idiopathic hirsutism

Urinary pregnanetriol and delta 5-pregnenetriol were determined in 90 normal women and in 90 women with idiopathic hirsutism of comparable age group. When group Student's "t"-test was carried out, the mean steroid excretion values in hirsute women were found to be significant with delta 5-pregnenetriol more significant than pregnanetriol. Of the 90 women with hirsutism, 8 patients had pregnanetriol and delta 5-pregnenetriol values higher than normal. When, on the basis of these elevated values, the women were sent for a thorough gynaecological investigation, they were found to have the polycystic ovary syndrome. After wedge resection, the diagnosis was confirmed and the urinary excretion of pregnanetriol and delta 5-pregnenetriol came down to a normal level. This study shows that, in the case of women with idiopathic hirsutism suspected of any ovarian disorder, the measurement of these two steroids could be of diagnostic importance.     

Plasma vitamin values and antiepileptic therapy: case reports of pregnancy outcomes affected by a neural tube defect

BACKGROUND: Folic acid supplementation reduces the occurrence of neural tube defects (NTDs); however, it is not clear whether it protects against teratogenic effects of antiepileptic drugs. METHODS: We report the cases of four pregnant women receiving valproic acid therapy, who all had NTD-affected offspring, despite periconceptional 5 mg/day of folic acid supplementation (cases), and investigated homocysteine metabolism, linked with folate metabolism. Their plasma homocysteine, folates, and vitamin B6 and B12 results were compared with values of two other women, who were also receiving valproic acid and folic acid complement, but who had normal pregnancies (valproic acid controls), and values of 40 pregnant women who had normal pregnancies and were not receiving any therapy (controls without therapy). Because of the possible existence of a genetic susceptibility, polymorphisms in homocysteine metabolism were sought. RESULTS: Two cases showed a decreased phosphopyridoxal level, compared with levels in the controls not receiving therapy. The genotype TT (C677T) is an NTD genetic susceptibility, but it was observed in only one valproic acid control. Various polymorphisms were observed in the cases, but were also common in the controls. Several studies have reported that valproic acid therapy lowers vitamin B6 levels. Our case with the greatest decrease in plasma phosphopyridoxal, who was taking periconceptional folic acid plus pyridoxine therapy, had a normal second pregnancy outcome. CONCLUSIONS: In addition to folates, other vitamins, such as vitamin B6, may have played a role in NTDs in our patients taking an antiepileptic drug.     

Reduced calcitonin reserve in young hypogonadic osteoporotic men

Calcitonin is a potent inhibitor of bone resorption and in both sexes, plasma levels progressively decrease with age: therefore, a relative deficiency of calcitonin may be involved in the pathogenesis of osteoporosis in the elderly. Calcitonin plasma levels of young hypogonadic men with osteoporosis are significantly lower than controls: the hypothesis that the decreased calcitonin plasma levels in the elderly are due to a reduced secretory capacity of the "C" cells of the thyroid gland, related to age, does not explain the low calcitonin plasma levels found in young hypogonadic osteoporotic men. Our hypothesis is that gonadal steroid deficiency may participate in the mechanisms regulating calcitonin secretion. Therefore, we studied ten males affected by hypogonadotropic hypogonadism and ten normal men, of comparable age, as controls: we measured plasma levels of testosterone, 17 beta estradiol, androstenedione and calcitonin, and the response of calcitonin to an i.v. bolus of pentagastrin, a well known "C" cells stimulatory drug. Testosterone and calcitonin plasma levels and the response of calcitonin to pentagastrin were also evaluated after 6 months of replacement therapy with testosterone. Basal levels of testosterone, 17 beta estradiol, androstenedione and calcitonin, and the response of calcitonin to pentagastrin, are significantly lower in our patients than in controls, demonstrating that hypogonadotropic hypogonadic subjects have a lower secretory reserve of calcitonin. After testosterone therapy the basal calcitonin plasma levels and its response to pentagastrin stimulus did not differ from controls, suggesting that gonadal steroids influence the calcitonin secretion and reserve. Our data cannot clarify whether osteoporosis of hypogonadotropic hypogonadic patients is related to androgen or estrogen deficiency; however, they suggest that the mechanisms by which gonadal steroid influence bone metabolism may involve calcitonin secretion.     

Effects of cadmium on the reproductive axis of Japanese medaka (Oryzias latipes)

Cadmium (Cd) is a ubquitous element and a significant inorganic pollutant that has previously been found to bioaccumulate in reproductive organs of fish and disrupt important endocrine processes, especially those involved in synthesis, release and metabolism of hormones. Clearly, there is potential for reproductive effects in fish populations exposed to Cd, however, few studies have investigated the non-lethal consequences of Cd in fish. To this extent, adult male and female Japanese medaka were exposed to 0-10 ppb Cd for 7 weeks. Reproductive endpoints were monitored during weeks 6 and 7 of exposure and compared to physiological responses along the hypothalamus-pituitary-gonadal (HPG) axis, including plasma vitellogenin (VTG), hepatic estrogen receptor (ER), plasma steroids, gonadal-somatic indices (GSI), and gonadal steroid release. There were no observed effects on VTG and ER by long-term Cd exposure. However, gonadal steroid release was significantly decreased in males and females at all exposure concentrations and female plasma estradiol levels were significantly altered at concentrations higher than 5 ppb Cd. Overall, responses along the HPG axis were more sensitive to Cd exposure than the reproductive and developmental endpoints, which were not affected in this study, indicating that higher level impairment in fish might be relatively protected.     

Effects of progesterone and 17-beta-oestradiol treatments on the pancreatic B cell castrated female rats. Biochemical variations.

The biochemical effects of progesterone and/or oestradiol treatments on castrated female rats have been compared to those of control olive-oil injections. 1. The steroid treatments used produced physiological concentrations of the two hormones in peripheral plasma, comparable to those obtained during pregnancy. 2. Glycemia remains within a normal range for all the treatments. 3. Circulating immunoreactive insulin (IRI) increases in the steroid-treated rats and the values reach those of the pregnant animals. 4. It was concluded that the biochemical modifications that occur during the steroid treatment (especially with the combined treatment) are quite comparable to what happens during pregnancy and explain, at least in part, the altered carbohydrate and lipid metabolism, and the hyperactivity in the B cell, resulting in an increased insulin secretion.     

Sex steroid binding protein (SBP) receptors in estrogen sensitive tissues

Since the discovery of a specific membrane binding site for sex steroid binding protein (SBP) in human decidual endometrium and in hyperplastic prostate numerous speculations have been raised on the existence of an additional non-receptor-mediated system for steroid hormone action. In the present work SBP cell membrane binding was investigated in human estrogen target tissues other than those previously studied either in the absence of steroids or in the presence of varying amounts (10⁻¹⁰−10⁻⁶M) of estradiol, testosterone and dihydrotestosterone, respectively. Plasma membranes obtained by differential centrifugation from homogenized samples of pre-menopausal endometrium, endometrium adenocarcinoma, normal liver and post-menopausal breast showed a specific binding of highly purified [¹²⁵I]SBP: a major displacement of labeled SBP was elicited by radioinert SBP, while no significant displacement occurred when other human plasma proteins were used as cold competitors (molar excess ranging 500–10,000-fold). A specific, time-dependent binding of [¹²⁵I]SBP was also observed in MCF-7 and in Hep-G2 cell lines. The different patterns of specific binding, observed in membranes from different tissues when SBP was liganded with different sex steroid molecules, leads us to consider the tissue individuality of the receptor as a further entity in the membrane recognition system for SBP.